Form CDC 57.140 CDC 57.140 Urinary Tract Infection (UTI) for LTCF

Form Approved

OMB No. 0920-0666

Exp. Date: xx/xxx/xxxx

www.cdc.gov/nhsn

Urinary Tract Infection (UTI) for LTCF

Page 1 of 4														*required for saving
*Facility ID:												Event #:
*Resident ID:
Medicare number (or comparable railroad insurance number):
Resident Name, Last:								First:												Middle:
*Gender: M F Other												*Date of Birth: ___/___/____
Ethnicity (specify):												Race (specify):
*Date of First Admission to Facility: __/__/____													*Date of Current Admission to Facility: __/__/____
*Event Type: UTI													*Date of Event: __/__/____
*Resident Care Location: __________________________
*Primary Resident Service Type: (check one)
□ Long-term general nursing							□ Long-term dementia										□ Long-term psychiatric
□ Skilled nursing/Short-term rehab (subacute)										□ Ventilator							□ Bariatric					□ Hospice/Palliative
*Has resident been transferred from an acute care facility to your facility in the past 4 weeks?																					□ Yes		□ No
If Yes, date of last transfer from acute care to your facility: __/__/____
If Yes, did the resident have an indwelling urinary catheter at the time of transfer to your facility?																						□ Yes		□ No
*Indwelling Urinary Catheter status at time of event onset (check one):
□ In place		□ Removed within last 2 calendar days									□ Not in place
If indwelling urinary catheter status in place or removed within last 2 calendar days:
	Site where indwelling urinary catheter Inserted (check one):								□ Your facility						□ Acute care hospital							□ Other			□ Unknown
	Date of indwelling urinary catheter Insertion: ___/___/_____
If indwelling urinary catheter not in place, was another urinary device type present at the time of event onset?																										□ Yes	□ No
	If Yes, other device type:					□ Suprapubic				□ Condom (males only)									□ Intermittent straight catheter
Event Details
*Specify Criteria Used: (check all that apply)																Laboratory & Diagnostic Testing
Signs & Symptoms
□ Fever: Single temperature ≥ 37.8°C (>100°F), or > 37.2°C (>99°F) on repeated occasions, or an increase of >1.1°C (>2°F) over baseline																□ Positive urine culture with no more than 2 species of microorganisms, at least one of which is a bacterium of ≥ 105 CFU/ml
□ Rigors				□ New onset hypotension
□ New onset confusion/functional decline
□ Acute pain, swelling, or tenderness of the testes, epididymis, or prostate
□ Acute dysuria				□ Purulent drainage at catheter insertion site
New and/or marked increase in (check all that apply):
□ Urgency				□ Costovertebral angle pain or tenderness												□ Leukocytosis (> 14,000 cells/mm3), or Left shift (> 6% or 1,500 bands/mm3)
□ Frequency				□ Suprapubic tenderness
□ Incontinence				□ Visible (gross) hematuria												□ Positive blood culture with 1 matching organism in urine culture
*Specific Event (Check one):
□ Symptomatic UTI (SUTI)					□ Symptomatic CA-UTI (CA-SUTI)													□ Asymptomatic Bacteremic UTI (ABUTI)
Secondary Bloodstream Infection: Yes No												Died within 7 days of date of event: Yes No
*Transfer to acute care facility within 7 days: Yes No
*Pathogens identified: Yes No					*If Yes, specify on page 2
Assurance of Confidentiality: The voluntarily provided information obtained in this surveillance system that would permit identification of any individual or institution is collected with a guarantee that it will be held in strict confidence, will be used only for the purposes stated, and will not otherwise be disclosed or released without the consent of the individual, or the institution in accordance with Sections 304, 306 and 308(d) of the Public Health Service Act (42 USC 242b, 242k, and 242m(d)). Public reporting burden of this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC, Reports Clearance Officer, 1600 Clifton Rd., MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0666). CDC 57.140 (Front) r3 v9.2

Urinary Tract Infection (UTI) for LTCF

Page 2 of 4
Pathogen #	Gram-positive Organisms
_______	Staphylococcus coagulase-negative			VANC S I R N
	(specify species if available): ____________
_______	____Enterococcus faecium ____Enterococcus faecalis ____Enterococcus spp. (Only those not identified to the species level)			DAPTO S NS N	GENTHL§ S R N		LNZ S I R N		VANC S I R N
_______	Staphylococcus aureus	CIPRO/LEVO/MOXI S I R N		CLIND S I R N	DAPTO S NS N	DOXY/MINO S I R N			ERYTH S I R N		GENT S I R N	LNZ S R N
		OX/CEFOX/METH S I R N		RIF S I R N	TETRA S I R N	TIG S NS N			TMZ S I R N		VANC S I R N
Pathogen #	Gram-negative Organisms
_______	Acinetobacter (specify species) ____________	AMK S I R N	AMPSUL S I R N	AZT S I R N	CEFEP S I R N	CEFTAZ S I R N			CIPRO/LEVO S I R N			COL/PB S I R N
		GENT S I R N	IMI S I R N	MERO/DORI S I R N		PIP/PIPTAZ S I R N					TETRA/DOXY/MINO S I R N
		TMZ S I R N	TOBRA S I R N
_______	Escherichia coli	AMK S I R N	AMP S I R N	AMPSUL/AMXCLV S I R N		AZT S I R N		CEFAZ S I R N		CEFEP S I/S-DD R N		CEFOT/CEFTRX S I R N
		CEFTAZ S I R N	CEFUR S I R N	CEFOX/CETET S I R N		CIPRO/LEVO/MOXI S I R N				COL/PB† S R N
		ERTA S I R N	GENT S I R N	IMI S I R N	MERO/DORI S I R N			PIPTAZ S I R N		TETRA/DOXY/MINO S I R N
		TIG S I R N	TMZ S I R N	TOBRA S I R N
_______	Enterobacter (specify species) ____________	AMK S I R N	AMP S I R N	AMPSUL/AMXCLV S I R N		AZT S I R N		CEFAZ S I R N		CEFEP S I/S-DD R N		CEFOT/CEFTRX S I R N
		CEFTAZ S I R N	CEFUR S I R N	CEFOX/CETET S I R N		CIPRO/LEVO/MOXI S I R N				COL/PB† S R N
		ERTA S I R N	GENT S I R N	IMI S I R N	MERO/DORI S I R N			PIPTAZ S I R N		TETRA/DOXY/MINO S I R N
		TIG S I R N	TMZ S I R N	TOBRA S I R N
_______	____Klebsiella pneumonia ____Klebsiella oxytoca	AMK S I R N	AMP S I R N	AMPSUL/AMXCLV S I R N		AZT S I R N		CEFAZ S I R N		CEFEP S I/S-DD R N		CEFOT/CEFTRX S I R N
		CEFTAZ S I R N	CEFUR S I R N	CEFOX/CETET S I R N		CIPRO/LEVO/MOXI S I R N				COL/PB† S R N
		ERTA S I R N	GENT S I R N	IMI S I R N	MERO/DORI S I R N			PIPTAZ S I R N		TETRA/DOXY/MINO S I R N
		TIG S I R N	TMZ S I R N	TOBRA S I R N

Urinary Tract Infection (UTI) for LTCF

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Pathogen #	Gram-negative Organisms (continued)
_______	Pseudomonas aeruginosa	AMK S I R N		AZT S I R N	CEFEP S I R N		CEFTAZ S I R N			CIPRO/LEVO S I R N			COL/PB S I R N		GENT S I R N
		IMI S I R N		MERO/DORI S I R N			PIP/PIPTAZ S I R N			TOBRA S I R N
Pathogen #	Other Organisms
_______	Organism 1 (specify) ____________	_______Drug 1 S I R N	_______ Drug 2 S I R N			______ Drug 3 S I R N		_______ Drug 4 S I R N	_______Drug 5 S I R N		______ Drug 6 S I R N	______ Drug 7 S I R N		______ Drug 8 S I R N		______ Drug 9 S I R N
_______	Organism 1 (specify) ____________	_______Drug 1 S I R N	_______ Drug 2 S I R N			______ Drug 3 S I R N		_______ Drug 4 S I R N	_______Drug 5 S I R N		______ Drug 6 S I R N	______ Drug 7 S I R N		______ Drug 8 S I R N		______ Drug 9 S I R N
_______	Organism 1 (specify) ____________	_______Drug 1 S I R N	_______ Drug 2 S I R N			______ Drug 3 S I R N		_______ Drug 4 S I R N	_______Drug 5 S I R N		______ Drug 6 S I R N	______ Drug 7 S I R N		______ Drug 8 S I R N		______ Drug 9 S I R N

Result Codes

S = Susceptible I = Intermediate R = Resistant NS = Non-susceptible S-DD = Susceptible-dose dependent N = Not tested

^§ GENTHL results: S = Susceptible/Synergistic and R = Resistant/Not Synergistic

^† Clinical breakpoints have not been set by FDA or CLSI, Sensitive and Resistant designations should be based upon epidemiological cutoffs of Sensitive MIC ≤ 2 and Resistant MIC ≥ 4

Drug Codes:
AMK = amikacin	CEFTRX = ceftriaxone	FLUCY = flucytosine	OX = oxacillin
AMP = ampicillin	CEFUR= cefuroxime	GENT = gentamicin	PB = polymyxin B
AMPSUL = ampicillin/sulbactam	CETET= cefotetan	GENTHL = gentamicin –high level test	PIP = piperacillin
AMXCLV = amoxicillin/clavulanic acid	CIPRO = ciprofloxacin	IMI = imipenem	PIPTAZ = piperacillin/tazobactam
ANID = anidulafungin	CLIND = clindamycin	ITRA = itraconazole	RIF = rifampin
AZT = aztreonam	COL = colistin	LEVO = levofloxacin	TETRA = tetracycline
CASPO = caspofungin	DAPTO = daptomycin	LNZ = linezolid	TIG = tigecycline
CEFAZ= cefazolin	DORI = doripenem	MERO = meropenem	TMZ = trimethoprim/sulfamethoxazole
CEFEP = cefepime	DOXY = doxycycline	METH = methicillin	TOBRA = tobramycin
CEFOT = cefotaxime	ERTA = ertapenem	MICA = micafungin	VANC = vancomycin
CEFOX= cefoxitin	ERYTH = erythromycin	MINO = minocycline	VORI = voriconazole
CEFTAZ = ceftazidime	FLUCO = fluconazole	MOXI = moxifloxacin

Urinary Tract Infection (UTI) for LTCF Page 4 of 4
Custom Fields
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